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72.19 -1 -33
BOX 26
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03215
PUTNAM COUNTY DEPARTMENT OF HEALTH
CERTIFICATE OF CONSTRUCTION COMPLIANCE FOR TMENT SYSTEM
PCHD CONSTRUCTION PERMIT #
Located at 4 ,._, /-//v ;�_
Owner /Applicant Name 'ea
Formerl C!a ,-7,,- c_ `e
Town or Village
Jw
Tax Map %19 Block / Lot
Subdivision Name Y'
Subd. Lot #
Mailing Address ! ,::, e r• 2t •''� xyeo
6.1 ;i��
/r , - _f r? ,
Date Construction Permit Issued by PCHD
Separate Sewerage System built by
J
Zip /c _:'24
& ;,y' /7 Gr Address --:r '1, 1-,.-7 4e
Consisting of : gLe c9 Gallon Septic Tank and
c� e Z��
Water analysis result for sodium (Na) is mg/L.
Other Requirements: °' Water containing more than 20 mu/i, of snclie +m shnuld not he used for
drinking by people on severely restricted sodium diets. Water containing
Water Supply: Public Supply,9l qW *,,,,, .,.,null tic n ,;,,,„ �i,,c� t�#; �+ h- a., 64 sa, - e% g ,rn,
or:� Private Supply Drilled by rese,odi� Pis"1
t ullaing type _ � :� 1`_ J z -e- Has erosioli colluul eea-coiupla(Z.l
Number of Bedrooms
Has garbage grinder been installed?
TH
I certify that the system(s), as listed, serving the above premises were constructed essentially as shown on the as-
built plans (copies of which are attached), in accordance with the issued PCHD Construction Permit and approved
plans and the standards, rules and regulations of the Putnam County Department of Health.
Date: e,,, Certified by
Address 7 ZZ a lJ/ +
Any person o pying premises served by the ab�
to secure the correction of any unsanitary conditions re
treatment system shall become null and void as soon as a
of the private water supply shall become null and void
approvals are subject to mo ' ication or change when
P.E. P-' R.A.
License #
Ktly take such action as may be necessary
L usage. Approval of the separate sewage
sewer becomes available and the approval
when a public water supply becomes available. Such
in the judgment of the Public Health Director, such
revocation o fic c e is necessary.
By: Title: Date: I Z 3 0
White copy - HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Design Professional
Form CC -97
a PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
WELL COMPLETION REPORT
Well Location
Street Address:
640 Sprout Brook Road
Town/Village:
Putnam Valley
Tax Grid #
Map V lffiock I Lot(s)S*�)
Well Owner:
Name: Address:
John Palka, 423 Sprout Brook Road, Garrison, NY 10524
Use of Well:
1- primary
2- secondary
X Residential Public Supply Air cond /heat pump Irrigation
Business Farm Test/monitoring Other(specify)
Industrial Institutional Standby
Drilling Equipment
X Rotary Cable percussion X Compressed air percussion Other (specify)
Well Type
Screened Open end casing X Open hole in bedrock Other
Casing Details
Total length 32 ft.
Length below grade 31 ft.
Diameter 6 in..
Weight per foot 19 lb/ft.
Materials: X Steel —Plastic _ Other
Joints:, Welded X Threaded, Other
Seal: X Cement grout _ Bentonite Other
Drive. shoe: X Yes No
Liner: Yes X No
Screen Details
Diameter (in)
Slot Size
Length(ft)
Depth to Screen (ft)
Developed?
First
Yes No
Hours
Second
Well Yield Test
Bailed X Pumped X Compressed Air
Hours 6
Yield 15 gprn
Depth Data
Measure from land surface- static (specify ft)
30'
During yield test(ft)
160'
Depth of completed well in feet
225'
Well Log
If more detailed
information
descriptions or
sicv s ul,s
are available,
please attach.
Depth From
Surface
Water
Bearing
Well
Diameter(in)
Formation
Description
ft.
ft.
Land Surface
10
Drilling
in over
urden clay and boulders
10
Hit rock
at 10'
iu
32'
y-Drillincll
iii r-ocK'
se "cas n routiea
32
225
Drilling
in rock
granite
Watat
nal sis re
ult for sodium
is mg/L.
Water
containing
more than
20 m
f sodium should not be used for
drinkitan
peop
a on sever
ly restricted
sodium diets. Water containing
more t
5'0 m
of sodi
m should
not be used by people on moderatel
restric
>lu
tats.
;f'U7N
M COUNTY DST. GF "FIEALTII
If yield was tested
at different depths
during drilling,
list:
Feet
Gallons Per Minute
Pump /Storage Tank Information
Pump Type sub Capacity 7cflm
Depth 180' Model 7GS05412
Voltage 230 HP
Tank Type M51 Volume 6 al.
Date Well Completed
8/4/00
Putnam County Certification No.
002
Date of Report
10/12/00
Well ril
NOTE: Exact location of well with "distances to at I st two permanent landmarks to be pro dMon a separate'sheet/plan.
Well Driller's Name P. e n Inc. Address: 4 Rtna¢n Ave., Brewster, NY 10509
Signature: Date: 10/12/00
F -ry X.
White copy: HD File; allow copy - Building Inspector; Pink copy - Owner; Orange copy - Well driller
Form WC -97
5 . [ N '**j
LABS
THEAST
T
L- LL111\ i�VLiL Ltl1\ D V 1C i V
(203) 748 -7903 - FAX (203) 748 -0652
PRY. or _DANBURY-... - -
06 11 CT Cert: PH -0404
NY Cert: 11471
PHYSICALS:
11/2/2000
10:00 A.M.
ADAM
11/2/2000
11/2/2000 N- 11/7/2000
LAB #11471
11/8/2000
MAXIMUM CONTAMINANT
LEVEL (MCL) OR STANDARD
•
LABORATORY REPORT
REPORT TO:
-
P.F. BEAL & SONS
DATE SAMPLE COLLECTED:
4 PUTNAM AVENUE
TIME COLLECTED:
BREWSTER, N.Y. 11509
COLLECTED BY:
-
DATE RECEIVED @ LAB:
•
DATE(S) TESTED:
7.22
TESTED BY:
EPA 150.1
REPORT DATE:
SAMPLE SITE:
PALKA, SPROUT BROOK RD., PUTNAM VALLEY, N.Y.
SAMPLE POINT:
TANK
SOURCE:
WELL
TREATMENT:
NONE
TEST PERFORMED
RESULTS METHOD #
PHYSICALS:
11/2/2000
10:00 A.M.
ADAM
11/2/2000
11/2/2000 N- 11/7/2000
LAB #11471
11/8/2000
MAXIMUM CONTAMINANT
LEVEL (MCL) OR STANDARD
•
Color (Apparent)
8
-
EPA 110.2
15
•
Odor
ND
-
-
3 Units
•
pH
7.22
-
EPA 150.1
No designated limits
•
Turbidity
1.6
NTUs
EPA 180.1
5 NTUs
CHEMISTRY:
•
Nitrite Nitrogen
0.017
mg/L as N
EPA 354.1
1.0 mg/L
•
Nitrate Nitrogen
<0.20
mg/L as N
SM 4500D
10 mg/L
•
Alkalinity
120.0
mg/L
SM 2320B
No defined limits
•
Hardness
154.0
mg/L
EPA 130.2
No defined limits
•
Iron
0.130
mg/L
EPA 236.1
0.30 mg/L
- -,-a
- Usraj2 nose
0.011.
rr►g/�
EPA 243..-
b
"
-
_ _ . s
_ „ .
-
Combined limit for Iron plus Manganese = 0.50mg/L
•
Sodium
22.0 **
mg/L
EPA 273.1
20.0 mg/L **
•
Lead
0.016 * **
mg/L
EPA 239.2
0.015 mg/L * ** .
ml= milliliter mg/L--milligrams per Liter ND =none detected MCL= Maximum Contaminant Level
. "Notification Level * "Action Level
COMMENTS:
-All holding times (were) met.
RESULTS BASED ON SAMPLES SUBMITTED: 11 /2/2000
Laboratory Director
b
•NORTHEAST LABORATORY, 129 MILL STREET, BERLIN, CT 060379 (860)828 -9787 - FAX (860)829 -1050
TOLL FREE WITHIN CT: 800 - 826 -0105 •OUTSIDE CT: 800 - 654 -1230
y o
NE
TT
39 MILL PLAIN ROAD - DANBURY, CT 06811 CT Cert: PH -0404
L"s 1 (203) 748 -7903 - FAX (203) 748 -0652 NY Cert: 11471
LABORATORY REPORT -- WATER SUPPLY TESTING
REPORT TO:
P.F. BEAL & SONS
4 PUTNAM AVENUE
BREWSTER, N.Y. 10509
SAMPLE SITE:
SAMPLING POINT:
SOURCE:
TREATMENT:
TEST PERFORMED
DATE SAMPLE COLLECTED:
TIME COLLECTED:
COLLECTED BY:
DATE RECEIVED @ LAB:
DATE(S) TESTED:
TESTED BY:
REPORT DATE:
9/26/2000
3:15 P.M.
C. SCRIVANOS
9/27/2000
9/27/2000
LAB #11471
9/23/2e00
PALKA, 640 SPROUT BROOK ROAD, PUTNAM VALLEY, N.Y.
TANK
WELL
NONE
RESULT:
RECOMMENDED LIMIT
BACTERIAL:
Total Coliform (Bacteria) 0 per 100 ml 0 per 100 ml
CHEMISTRY:
Chlorine Residual ND mg/L - - - --
ml = milliliter
mg/L = milligrams per Liter
ND = none detected
RESULTS BASED ON SAMPLES SUBMI PTED:9 /27/2000
SAMPLE, AS TESTED ABOVE: DOTABLE or AMNOTPOTABLE
(PER STATE OF NEW YORK DEPT. OF HEALTH SERVICES STANDARDS FOR POTABLE WATER)
Laboratory Director
*NORTHEAST LABORATORY, 129 MILL STREET, BERLIN, CT 06037• (860)828 -9787 - FAX (860)829 -1050
TOLL FREE WITHIN CT: 800 - 826 -0105 . OUTSIDE CT: 800 - 654 -1230
-T R, ,.R7
423 Sprout Brook Road
Garrison, NY 10524
(845) 788 -4099
January 22, 2001
Mr. Adam Stiebeling
Department of Health.
1 Geneva Road
Brewster, NY 10509
Re: Application of Certificate of Construction
Compliance - Palka,. Sprout Brook Road
(T) PV TM #72.19 -1 -33
Dear Mr. Stiebeling:
Per your correspondence of December 28, 2000, enclosed please find the water re -test you
requested.
Please call me if you require any additional information.
Very'truiy yours,
Adriana Palka
¢¢
i�f
.'/:..a...' . - ..... . _. _ .. — -.� � �.� -� �. -. .� .- �q �J+i..P.. �_..�• It q .4 ST �
V� 39 MILL PLAIN ROAD - DANBURY, CT 06811
L"s 1 (203) 748 -7903 - PAX (203) 748 -0652
CT Cert: PH -0404
NY Cert: 11471
CHEMISTRY:
• Sodium 24.3 ** mg/L EPA 273.1 20.0 mg/L**
• Lead 0.001 mg/L EPA 239.2 0.015 mg/L * **
ml= milliliter mg/L= milligrams per Liter ND =none detected MCL= Maximum Contaminant Level
" "Notification Level ** *Action Level
COMIVIENTS:
-All holding times (were) met.
r
R')♦:- SU"L'I'S �3ASED ON SA�VIa'�ES SiJB1NY`1'1'r�ll:f /372061- �.�,°..'.. ° ,-....--_ � ._.- — •- -- s _- ...,__,._.^. __.__._....... _....- ....__, „
�.
Laboratory Director
Water analysis result for sodium (Na) is 01 - � mom-• .
Water containing more than 20 mg/L, of sodium should not be used for
drinking by people on severely restricted sodiu=n diets. Water containing
more than 270 rng[L, of sodium should not be us Ad by people on moderately
restricted sodium diets. l✓'UT1 kM, COT'IN` Y DEPT. OF HEALTH
•NORTHEAST LABORATORY, 129 MILL STREET, BERLIN, CT 06037• (860)828 -9787 - FAX (860)829 -1050
TOLL FREE WITHIN CT: 800 - 826 -0105 •OUTSIDE CT: 800 - 654 -1230
LABORATOR`St REPORT
REPORT TO:
P.F. BEAL & SONS
DATE SAMPLE COLLECTED:
1/3/2001
4 PUTNAM AVENUE
TIME COLLECTED:.
11:00 A.M.
BREWSTER, N.Y. 10509
COLLECTED BY:
ED. SCHAEFFLER
DATE RECEIVED @ LAB:
1/3/2001
TESTED BY:
LAB# 11471
LAB l:D.#
PFB001
REPORT DATE:
1/9/2001
SAMPLE . SITE:
PA1KA, SPROUT BROOK RD., PUTNAM VALLEY, N.Y.
SAMPLE POINT:
KITCHEN SINK
SOURCE:
WELL
TREATMENT:
NONE
MAXIMUM CONTAMINANT
TEST PERFORMED
RESULTS METHOD # ..
LEVEL (MCL) OR STANDARD
CHEMISTRY:
• Sodium 24.3 ** mg/L EPA 273.1 20.0 mg/L**
• Lead 0.001 mg/L EPA 239.2 0.015 mg/L * **
ml= milliliter mg/L= milligrams per Liter ND =none detected MCL= Maximum Contaminant Level
" "Notification Level ** *Action Level
COMIVIENTS:
-All holding times (were) met.
r
R')♦:- SU"L'I'S �3ASED ON SA�VIa'�ES SiJB1NY`1'1'r�ll:f /372061- �.�,°..'.. ° ,-....--_ � ._.- — •- -- s _- ...,__,._.^. __.__._....... _....- ....__, „
�.
Laboratory Director
Water analysis result for sodium (Na) is 01 - � mom-• .
Water containing more than 20 mg/L, of sodium should not be used for
drinking by people on severely restricted sodiu=n diets. Water containing
more than 270 rng[L, of sodium should not be us Ad by people on moderately
restricted sodium diets. l✓'UT1 kM, COT'IN` Y DEPT. OF HEALTH
•NORTHEAST LABORATORY, 129 MILL STREET, BERLIN, CT 06037• (860)828 -9787 - FAX (860)829 -1050
TOLL FREE WITHIN CT: 800 - 826 -0105 •OUTSIDE CT: 800 - 654 -1230
Public Health Director
YARI'� TAy IvfOLINARI RN., M.S.N. .r.-
Associate Public Health Director
Director of Patient Services
DEPARTMENT OF HEALTH
1 Geneva Road
Brewster, New York 10509
Environmental Health (914).278 - 6130 Fax (9.14) 278 - 7921
Nursing Services (914) 278 - 6558 WIC (914) 278 - 6678 Fax (914) 278 - 6085
Early Intervention (914) 278 - 6014 Preschool (914) 278 -6082 Fax (914) 278 - 6648
Ow1VERS NAME:
TAX MAP NUMBER:
E911 ADDRESS:
TOWN:
AUTHORIZED TOWN OF
(Signature)
DATE:
RUM
J014-AJ ,ELI -A _) i4
�;zn00
The Putnam County Department of Health will not issue. a Certificate of
Construction Compliance unless the above form is completed, i.e., a legal E911
address is assigned by an authorized town official. This form is to be submitted
with the application fora Certificate of Construction Compliance.
(E911 VERFR O
+i
i
1
10/30/2000 10:41 9149624248 JOSEPH SULLIVAN PAGE 01
PUTN . COUNTY DEPARTMENT OF HEALTH
GUARANTEE OF SU'BSURFAC'E SEWAGE TREATMENT SYSTEM
Owner or Purchaser of Building Tax Map Bloc�k / Lot
Building Constructed by TowntVillage
Location - Street
Subdivision Name
Building Type Subdivision Lot #
I represent that I am wholly and completely responsible for the location, workmanship, material,
construction and drainage of the sewage treatment system serving the above - described property, and
that is has been constructed as shown on the approved plan or approved amendment thereto, and in
accordance with the standards, rules and regulations of the Putnam County Department of Health, and
hereby guarantee to the owner, his successors, heirs or assigns, to place in good operating condition
any part of said system constructed by me which fails to operate for a period of two years
immediately following the date of approval of the "Certificate of Construction Compliance" for the
sewage treatment system, or any repairs made by me to such system, except where the failure to
operate properly is caused by the willful or negligent act of the occupant of the building utilizing the
system.
-..� .... ...m.....,. -., .a.�— - es- ..:,i.�-... e„�.ae ... .�.,...ea -a . -,.. -- .. .. ..�.. .... _' V
The undersigned. further agrees to accept "as conclusive the determination of the Pub bic Health
Director of the Putnam County Department of Health as to whether or not the failure of the system
to operate was caused by the willful or negligent act of the occupant of the building utilizing the
system.
Dated: Month 1 I Day r j Year (I t�
General Contract r (Owner) - Signature
Corporation Name (if corporation)
Address:
State
Zip
Signature: +✓
Title:
Corporation Name (if corporation)
Address:r�3 wit Z51 �ti
State CWVI�0(\ � K\ Zip 101_ cl�
Form GS -97
BRUCE R. FOLEY LORETTA MOLINARI R.N., M.S.N.
: ;.::,.,.- '- .d'-- ° ^�u.G':;� 'x�.3:�'!� :,�A� &bt.Ai-...M,.. „ �,. >_:�::.:__. -..> :°:a', .. _ �•� • ........cam_ _ ...�., -,� -, ....L ?,f'..:.�'..iC /.,1� ,t�'v.t:�:F � s 3.... � _,. ._
w i Director of Patient Services
DEPARTMENT OF HEALTH
1 Geneva Road
Brewster, New York 10509
Environmental Health (845) 278 - 6130 Fax (845) 278 - 7921 }•B
Nursing Services (845) 278 - 6558 WIC (845) 278 - 6678 Fax (845) 278 - 6085®
Early Intervention (845) 278 - 6014 Preschool (845) 278 -6082 Fax(845)278 - 6648
December 28, 2000
Mr. Frank Sullivan
2972 Ferncrest Drive
Yorktown Heights, NY 10598
Re: Application of Certificate of Construction
Compliance - Palka, Sprout Brook Road
(T) PV TM #72.19 -1 -33
Dear Mr. Sullivan:
This office has determined that the above referenced Certificate of Construction Compliance
application, received on_December 26, 2000is_incomplete. Please be_ advised _that -the following
information is required before the Department may commence its review.
1. Submission of Satisfactory Water Quality Analysis for the following parameter(s):
• Sodium 20.0 m0
• Lead 0.015 -9"
'• 1 \I.J LIl LJ JLi Vi1L LLC%.L UoLUUln L, ..V i
Lead 0.019 m9A
Z3 0
Water must be re- tested and results re- submitted.
This office will.continue its review. upon receipt of the above - mentioned comments. Please feel
free to contact this office if any questions arise.
Very truly yours,
Adam B. Stiebeling
Assistant Public Health Engineer
ABS /jp
Z
Ad -AaPalka .:
423 Sprout Brook Road
Garrison, NY 10524
(914) 788-4099
December 21, 2000
Putnam County Health Dept
I Geneva Road
Brewster, NY 10509
Attn: Theresa
Dear Theresa:
Per our conversation yesterday, enclosed please find copies of the following permits
issued by your office:
• Construction Permit for Sewage Treatment System
• Application to Construct a Water Well Permit
• Sewage Disposal System Plan
Please call me at 914-737-4403 ext. 229 during business hours if you require any
additional information.
Very truly yours,
Adriana Palka
Complaint Information
- .. - ._:, -�._ ".-''3 °� ^' e`?-. ..�., •�amn'�3r..! -oac :.v^d; "e� .�,.w0,' ^�a� .
nplainant (Person Making Complaint)
First: MARTIN Last: ALBERT
Address:. 638 SPROUT BROOK RD
- Source of Complaint
Source: ADJACENT HOUSE
Address: SPROUT BROOK RD.
Phone: - -
-Location: Town of PUTNAM VALLEY
Operation Type: Nuisance (Public Health)
Category: Sewage Exposure
Assigned To: Stiebeling, Adam
Phone: 941 - 923 -8342
City: PUTNAM VALLEY State: NY Zip:
Facility Address:
Sub -LHU:
Risk Level:
Facility /Operation
i,
— Complaint
Nature of Complaint Date
Complaint Sewage exposure Status Needs Investigation Resolved
Description: ActionTaken:
UNDER WATER WHICH EXTENDS ONTO HIS PROPERTY
sw
C�
Page 1 of 1 Date Printed April 04, 2001
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Town of,'. illage
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r, . r Subd Lot # 324 Tax Map %. °i
�i2. ` Date of revious Approval
r9l GC Lot Area No of Bedrooms Design Flow GPDQ
t �
+ill Section Only * iDeptti F ' Volume
;J to = .. _ .
i- NOTIFICATION -T —D WHEN ftk —tg- COMPLETED".:
fo consist of �w %OD Y/, � gallon septic tank and � �% a' . {
ti✓F..r�i!" ' Address
Public Supply From x �Y�� Address
S �j '� -�. ✓.rx�+.ti..r�.t*�,, } ?,''�' �C °...{ i" i'v c,. .�t 4 1 , °: ''Nt ;hC ski �'ra, °cr'i� h,i:_,.}.v"�, -. �+r .1�-n '�'Y n. '��-,f. F r
4 ny -. °�'..r.ts... -t^,�*r�y'�"'��,��r �v. y+d.� i �1r_ � - T�,res,�t�q t� 3 ::.�..�F '.� a �, t y •'�'�+.- rfC.�.ti.� YS�i �'} y. _ _
and coin leiel re nsible foF thetdes an locabori of tfie fe' osed stems and that the
P P SX ()
describect,,atiovrewl{ be constructed as shown on the approved amendment (hereto din
<.r }'xei.'�- 3�'f•�t�� �ea.-� ^ -r•�as:' ,:+cc}'.# =at` ^w r�" a L y�,�W^"`�.sf�i $�,,,'. 7 �, n f �...:, px 1 �.)
ds, rules and reguiaions of thePuhiam Couirty�Department of Health, and tha on �t comn p etion `
g '`,�vaw.s ♦ Y - C - x`s r ys`•'cr- r An_ ,' Y' e v 4 " .•o` r z-( _ J ..,...
uiimediately following the date of the issuance ofthe `7 val of the Ceihfica� of Construction Compliance of the original
rtL
li� system or any repairs thereto,
Signed �: 8 A `Date
Address. !`AlG'!"
'
,r�
APPROVED CONSTRUCTION This royal expues o years from the date issued unless constructioit4of the
sewage treatment system has been completed and' inspected by a PCHD and is revocable for cause or, may be amended or,
.modified =when considered necessary by -the Public Health Director Any. rev ision or aheration'of el requires'
K a. newYpermit. Approved, for discharge of domestic sanitary _sewage only
•Cf' F.x 4! ,rev:,; ♦`- 4 aFs . iy.'M *+'i -t ,�. _. +yY+.Y.1 5 .i4 ?i
,3L Y itle �. Date i
�`` :xa a: >v; dv?,i�:x.�'?ti ra iv: ak •fr . r � > _.at�'`u #.�` -. 1t xkr1... Zj'y ."�c` :x ??-1 'fk_
ry White copy HD File, Yellow copy g Inspector, Pink copy Owner, Drarige copy Design fessionaT
s x Form CP 97
z e
er Street dre s{ r ,, .own' i f lage Cfty` aTx ,Grid. Numb
/ e
Aryr�' ca YY' sg e Y
PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH ERVICES
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CONSTRUCTION PERMIT FOR SEWAGE TREATMENT SYSTEM
PERMIT # 14 — 21-94 31 e -A 6 64 L
Located at �,nr�ra . /i^re�✓
Subdivision name Ccr.� � . \[ s Subd. Lot # 3 -z
Date Subdivision Approved
Owner /Applicant Named %�G,•'
Mailing Address _4 .:2.
Amount of Fee Enclosed
Town or Village 44 "1 '1 r
,L'
Tax Map 92. / V Block _- Lot 33
Renewal Revision .
&aw A-Is t r"
Date of Previous Approval Z —Z3
r„ f Ord W.
ZiplC�2-11
Building Type %7�%C C�7 �� Lot Area No. of Bedrooms 3 Design Flow GPD zeO
Fill Section Only Depth Volume
PCHD NOTIFICATION IS REQUIRED WHEN FILL IS COMPLETED
Separate Sewerage System to consist of % ee 11 gallon septic tank and
de
Other Requirements:
To be constructed by 67y;-- Address
Water Supply: Public Supply From Address
_. • or* Private Supply Drilled'by
I represent that I am wholly and completely responsible for the design and location of the proposed system(s) and that the
separate sewage treatment s, sy tem described above will be constructed as shown on the approved amendment thereto and in
accordance with the standards, rules and regulations of the Putnam County Department of Health, and that on completion
thereof a "Certificate of Construction Compliance" satisfactory to the Public Health Director will be submitted to the
Department, and a written guarantee will be furnished the owner, his successors, heirs or assigns by the builder, that said
builder will place in good operating condition any part of said sewage treatment system during the period of two (2) years
immediately following the date of the issuance of the approval of the Certificate of Construction Compliance of the original
system or any repairs thereto. M,
Signed: sod P R.A. Date
Address c G 5 t ` A License # y ,WSJ
'i'
APPROVED V C0NSTRUCTIO )1: This expires o years from the date issued unless construction of the
sewage treatment system has been completed and inspected by a PCHD and is revocable for cause or may be amended or
modified when considered necessary by the Public Health Director. Any revision or alteration of the approved plan requires
a new permit. Approved for discharge of domestic sanitary sewage only.
By: Title: j k � Date: 11
White copy - HD File; Yellow copy - ng Inspector; Pink copy - Owner; Orange copy - Design P ofessional
Form CP -97
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DEPARTMENT OF HEALTH
ivision of Environmental Health Services
4 Geneva Road, Brewster, New .York 10509
(914) 278 -6130 _t
r A.:la:..T:r:•q.T/y� "r1.y.fr T�.pp Y.s.t- � >'.t. :rNV'— �af:di, iy.�� ?.r4'n'6�V s ai'n,,:�w..r.� x'.9.3. '.'!^!. P':_�rl .l!
PLICATION TO CONSTRUCT A�WATER WELL -��
PCHD PERMIT
WELL LOCATION
Street Address own Vi lage City Tax Grid Number
,d a 7 (rd�%% %�d � I i a »� eo f�e " -,r r
WELL OWNER
"'Name Mailing Address
/ Private
i1Ur7AIJ O Publis
USE OF . WELL
1 — primary
2 - secondary
RESIDENTIAL 0 PUBLIC SUPPLY - 0 AIR /COND /HEAT PUMP /D ABANDONED
BUSINESS 0 FARM 0 TEST /OBSERVATION 0 OTHER (specify
® INDUSTRIAL M INSTITUTIONAL 0 STAND -BY
AMOUNT OF USE
YIELD SOUGHT _gpm /# PEOPLE SERVED_ /EST. OF DAILY USAGE oG al
® REPLACE EXISTING SUPPLY 0 TEST/ OBSERVATION 12. ADDITIONAL SUPPLY
NEW SUPPLY NEW DWELLING ® DEEPEN EXISTING WELL
REASON FOR
DRILLING
DETAILED
REASON FOR
DRILLING
WELL TYPE
DRILLED
®
DRIVEN
®DUG ® GRAVEL
0 OTHER
IS WELL SITE SUBJECT TO FLOODING? YES yam' NO
IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION: �!
Lot No.
WATER WELL CONTRACTOR: Name /V'd2�d.soi7 Address: "tu�
IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES d-" NO
NAME OF PUBLIC WATER SUPPLY: TOWN /VIL /CITY
.. = =1!?. •TLS- °P�L'1?Fy�2`Y FRO::•:
LOCATION.SKETCH & SOURCES OF CONTAMINATION PROVIDED
ON SEPARATE SHEET f
( ate (s gnature)
PERMIT TO CONSTRUCT A WATER WELL
This permit to construct one water well as set forth above is granted under the provisions
of Subpart 5 -2 of Part 5 of the New York State Sanitary Code, and provided that within
thirty (30) days of the completion of water well construction, the applicant shall:
1. Pump the well until the water is clear.
2. Disinfect the well in accordance with the requirements of the Putnam County Health
Department attached to this permit.
3. Submit a Well Completion Report on a form provided by the Putnam County Health Department.
During all well drilling operations, the applicant shall take appropriate action to assure that
any and all water or waste products from such well drilling operations be contained on this
property and in such a manner as not to degrade or othe ise c a ce or groundwater.
Date of Issue: I 19� _. -.
Date of Expiration 19 0� Permit Issuing Official
Permit is Non- Transferra le White copy: HD File Pink copy: Owner
3/89 Yellow copy: Bldg. Insp. Orange copy: Well Driller
s --
PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
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LETTER OF AUTHORIZATION
RE: Property of 14 a
Located at d
TNV I,w' v Tax Map # Block f Lot 3-3
Subdivision of
Subdivision Lot #
Gentlemen:
This letter is to authorize !;,I -e
Filed Map #
Date Filed
a duly licensed Professional Engineer ?for Registered Architect to apply for the required
wastewater treatment and/or water supply permit(s) to serve the above -noted property in accordance
with the standards, rules or regulations as promulgated by the Public Health Director of the Putnam
County Health Department, and to sign all necessary papers on my behalf in connection with this
matter and to supervise the construction of said wastewater tretment and/or water supply system's in
conformity with the.nrovisions.ofArticle .145. and/ /or_1.47.of the Education Law. - tbe_PubiiQ.Health_..,__,< -- -.:
- - - Law,`and the Putnam County Sanifary Code.'_'___......_.__ ._ __. . __:�___�...._....._.._�...
Countersigned:
P.E., . *<, # ?— Gl �
Mailing
State
Telephone:
Very truly yours,
Signed:
Owner of Property) '
Mailing Address:
OK
State Zip,
Telephone: 7,F9' 15( d ?-f
Form LA -97
t - a-/ 3 q _ Z-,J
PUTNAM COUNTY DEPARTMENT OF HEALTH -
DIVISION Of ENVIRONMENTAL HEALTH SERVICES
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CONSTRUCTION PERMIT FOR SEWAGE TREATMENT SYSTEM
PERMIT # PV 2ly— ?# A- rr 6 W10
Located at Town or Village V,/le-y
Subdivision name Subd. Lot # 3 A Tax Map ?2. 9_ Block / Lot -3-3
eZ1,1 -ge
Date Subdivision Approved Al 3 Renewal v' Revision
Owner /Applicant Name
Date of Previous Approval Z /l p g
Mailing Address �4 57, T-Y_
�i/r��i4
���vtib�/'
%��N��ii r� y V,X_ Zip 6s'
Amount of Fee Enclosed Oel
�¢G
Building Type el e. Lot Area /ems No. of Bedrooms 3 Design Flow GPD �acj
Fill Section Only Depth Volume
PCHD NOTIFICATION IS REQUIRED WHEN FILL IS COMPLETED
Separate Sewerage System to consist of /o a o gallon septic tank and 3 d eJ k ec
Other Requirements:
To be constructed by ell- Address -,49 4, , 14,6y
Water Sumoly: Public Supply.From __ Address
or: Private Supply Drilled by /V' 2rJ �� _ _ Address drr� a
I represent that I am wholly and completely responsible for the design and location of the proposed system(s) and that the
separate sewage treatment system described above will be constructed as shown on the approved amendment thereto and in
accordance with the standards, rules and regulations of the Putnam County Department of Health, and that on completion
thereof a "Certificate of Construction Compliance" satisfactory to the Public Health Director will be submitted to the
Department, and a written guarantee will be furnished the owner, his successors, heirs or assigns by the builder, that said
builder will place in good operating condition any part of said sewage treatment system during the period of two (2) years
immediately following the date of the issuance of the approval of the Certificate of Construction Compliance of the original
system or any repairs thereto.
Signed: � . 0&, P.E. �' R.A. Date
Address d/ License #
5�a tf^ r.Y d
APPROVED FOR C® TU�`TIOT,lls approval expires two y s from the date issued unless construction of the
.
sewage treatment system h ..Been completed and inspected by the PCHD and is revocable for cause or may be amended or
modifi d when considered necessary_.by °the Public Health Director. Any revision or alteration of the approved plan requires
anew a it. Approv r discharge of domestic sanitary se age only.
By: Title: Date:
copy - HD File Ye ow c py - Building Inspector; Pink copy - ner; Zge copy - Design Professional
Form CP -97
PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
APPLICATION TO CONSTRUCT A WATER WELL - t
-Please print or typo Y PCHll' Permit #
Well Location:
Street Address: Town/Village Tax Grid #
Map ;:; f lock Lot(s)-
Well Owner:
e:
Address:
Use of Well:
Residential Public Supply Air /Cond/He ump Irrigation
1- primary
Business Farm Test/Monitoring Other (specify)
2- secondary
Industrial Institutional Standby
Amount of Use
Yield Sought _ 5 gpm # People Served Est. of Daily Usage Ve al.
Reason for
Replace Existing Supply Test/Observation Additional Supply
Drilling
/New Supply (new dwelling) Deepen Existing Well
Detailed Reason
for Drilling
Well Type
rilled Driven Gravel Other
Is well site subject to flooding? ................................................. ............................... Yes - N o .✓'
Is well located in a realty subdivision? ...................................... ............................... Yes No
Name of subdivision Lot No.
Water Well Contractor: A,'or wey , 62;g ,,- y`y Address:
Is Public Water Supply available to site? .................................. ............................... Yes No J'
Name of Public Water Supply: -- Town/Village
Distance to property from nearest water main:
Proposed well location & sources of contamination to be provided on sepaarate//shheet/plan.
�!l'�`v •• /� An plicant SidaC41i� / /_. / I ✓i i�',.'__`,,,,-"----- ___..__''.---- •- ..'' - -• - -i
- -`_ .._
PERMIT TO CONSTRUCT A WATER WELL
This permit to construct one water well as set forth above, is granted under provisions of Article 10 of the
Putnam County Sanitary Code and Subpart 5 -2 of Part 5 of the New York State Sanitary Code and provided
that within thirty (30) days of the completion of water well construction, the applicant or their designated
representative shall: 1) Pump the well until the water is clear. 2) Disinfect the well in accordance with the
requirements of the Putnam County Health Department. 3) Submit a Well Completion Report on a form
provided by the Putnam County Health Department. During all well drilling operations, the applicant and/or
well driller shall take appropriate action to assure that any and all water and waste products from such
well drilling operations be contained on this property and in such a manner as not to degrade or otherwise
contaminate surface or groundwater.
APPROVED FOR CONSTRUCTION: This approval expires two years from the date issued unless
construction of the well has been completed and inspected by the PCHD and is revocable for cause or may be
amended or modified when considered necessary by the Public Health Direct Any revision or alteration
of the approved plan requires a new permit. Well to be constructed by a Ovate ell dril4certifiyl utna m
County.
Date of Issue Permit Issui Official:
Date of Expirati Title:
Permit is Non- ransferrable
White copy- HD file; Yellow copy- Building Inspector; Pink copy - Owner; Orange copy -Well driller
Form WP -97
� a
4
FeUTNAM C )LINTY DEPARTMENT OF HEALTH
APPLICATION FOR APPROVAL OF PLANS FOR A WASTEWATER DISPOSAL - SYSTEM
-
1 Name and Address of Applicant: d�' /0�✓ (�C� �Zv ��
2 `Name;,of Project: C�>. 5 . 3. Location T /V /C: A11w i j5e.
4 Project Engineer; d �d!! /y�� p - 5. Address: ? e�
License Number:��5/ Phone:
„.
6. Iyp�
of.Project .
ri.v:ate %Resi.dential Food Service ` Commercial
Apartments Institutional Mobile Home Park
Off ice.Buiad,ing Realty Subdivision Other (specify)
7. ,1. this project subject to State Environmental Quality Review (SEAR)? Ale
hCR� ,status (Check One) Type I.. Exempt
; w r '
Type II. Unlisted `
8 Is a D:raft,Env':i;ronmental Impact Statement (DEIS) required? ............. w
9, Has DEIS been completed and.found acceptable by Lead Agency? . ...........
10 Name of Lead Agency
ti R *.e thi.a �r:�i_ar ?_!! a►?_ {fir fit} .0 n cirr the r;nr t.ra t ;,f -'ocal . o lash n7a' or,ir�4,
o:r0other.off:icials, ordinances? ..e ........... ............••.
12. If so ''have plans been submitted to such authorities? ................... mss_
13. Has : pr -elimi,nary approval been granted by such authorities? Date Granted:
14. Type.of Sewage Disposal System Discharge...... Surface Water 11o"'Ground Waters
15. Jf .su:r-face water discharge, what is the stream class designation ?........ 1
16. Waters index number (surface) ...................... 441 17. Is project located near a public water supply system? .................. A
1.8. If yes, name of water supply Distance to water supply 'A��A_J
19 Is. project site near a public sewage collection or disposal system ?..... �U
20. Name of sewage system Distance to sewage system
-� ,A /M%rr /.5
2:1 ate test holes observed. 22. Name of Health Inspector:n
23 Project design,,flow (gallons per day)...., d a............................
11/9f3�:> •
s -
k�s
2 .
24. Is:.State Pollutant Discharge Elimination System (SPDES) Permit required ?..
Alel
25. Has SPDE$`Applicat -ion bee n submi tted to local DEC Office? ................
`—
,.,
26. Is.any portion- of.thi,s project located within a designated Town or State
wettland9 ..,....'.... ...., ............. .... ... ........ ...........
o
27 Wet,l.and I .........................
,. ;
28. Is Wetland - Permit required? ................... ........... ..............
been `made to Town DEC Office?
Has application or.Local ..................
c1
AlU
29. Does project require a DEC Stream Disturbance Permit? ....................
30. I,s.or was project site used for agricultural activity involving application
of pesticides to orchards or other crops, solid or hazardous waste disposal,
1andfi_lling,'s.lu0ge application or industrial activity? ........ YES or NO
o
31. Is project located within 1,000 feet of existence of abandoned landfill,
hazardous waste site, salt stockpile, landfill, sludge disposal site or
an other potential known source of contamination? ..............YES or NO
DESCRIBE:
32. Is .there a local master plan or file with the Town or Village? ...........t�'
33. Are community water, sewer facilities planned to be developed within 15 years?
34. Are any sewage disposal areas in excess of M slope? ........................
Alv
3 .
35. Tax Map .ID Number . 7 .. " .... �............
.. •••
=.
36 Approved Plans are to be returned to: ................ Applicant _�/ Engineer
If the application is signed by a person other than the applicant shown in Item 1, the
application must be accompanied by a Letter of Authorization. Failure to comply with this
pr9y.f,' n�may be grounds -for-the rejection of any submission.
I hereby affirm, under penalty of perjury, that information provided on this
form is true to the best of my knowledge and belief. False statements made
herein are punishable as a Class A Misdemeanor pursuant to Section 210.45 of
-the Pena 1 Law. �. / n
SIGNATURES & OFFICIAL TITLES:
J /
rM
PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
DESIGN DATA SHEET - SUBSURFACE SEWAGE TREATMENT SYSTEM
Owner , r,,h 7..,� 1 Address sLi /Vev-ol
Located at (Street) Tax Map9Block / Lot
(indicate nearest cross street)
Municipality '��� f�,y Watershed
SOIL PERCOLATION TEST DATA
Date of Pre - soaking Date of Percolation Test
NOTES: 1. Tests to be repeated at same depth until approximately equal percolation rates are obtained at each
percolation test hole. (i.e. s 1 min for 1 -30 min/inch, s 2 min for 31 -60 min/inch) All data to be
submitted for review.
2. Depth measurements to be made from top of hole.
Form DD -97
1
"0' '/yY'
/9-
2L
2
>F/'046
`,%'
'P" >'
3
#4, &A
4
5
4
5
1
2
3
4
5
NOTES: 1. Tests to be repeated at same depth until approximately equal percolation rates are obtained at each
percolation test hole. (i.e. s 1 min for 1 -30 min/inch, s 2 min for 31 -60 min/inch) All data to be
submitted for review.
2. Depth measurements to be made from top of hole.
Form DD -97
TEST PIT DATA
DESCRIPTION OF SOILS ENCOUNTERED IN TEST HOLES
DFPTH HOLE NO.f / y
G.L.
0.5'
1.0'
2.0'
2.5'
3.0'
3.5'
4.0'
4.5'
5.0'
5.5'
6.0'
6.5'
7.0'
HOLE NO. HOLE NO
✓�dr✓i�i �li� /��L
2
7.5'
8.0'
8.5'
�.. ... �«v .�. -w ...- +.T!mrn .� ..-... «--r. .��_�. ._ _ ✓i —«v u- --...a ... _.+...� -.. «v« rt _- .«�.. «,._w «..rs r....� ...- ria -.ur w- «�. «.w- w..r- •............. r-- ��.- ..o-- ....•y_ .� -.r.�.
9.5' -
10.0'
Indicate level at which groundwater is encountered We'a G
Indicate level at which mottling is observed
Indicate level to which water level rises after being encountered e
Deep hole observations made by: Date 2 2,L
Design Professional Name: 7— : Z, -- /�
Address: rc i re
Signature:
Design Professional's Seal
WESTCHESrER COUNTY DEPARTMENT OF HEALTH
19 Bradhurst Avenue
;iawthorne, New York 10532
DESIGN DATA SHEET - SEPARATE SEWEERAGE SYSTEM FILE NO_
Owner AddressJ!`���G�
y
Located at (Stceet) y /�i�y�j Sec.Z?l Block % Lat3 --3
ndi.cate nearest cross St_
Municipality / �/L' Watershed
SOIL PERCOLATION TEST DATA ROQOIRED TO BE SUBMITTED WITH APPLICATION
HOLE #
CLOCK TIME
PERCOLATION
Hole
Number
No.
Start Stop
Elapse
Time
Min.
Depth to water
From Grd Surface
Start Stop
Inches Inches
Water Level
In Inches
Drop
In Inches
Soil
Rate
Min /In
Drop
1
�p
26F
LSD
��i
�i�
e/5
3�'
4
5
2
3�
4
5
2
.
3
4
5.
LVUL�S:
1T—Tests to be repeated 3t same depth until approximately equal soil rates
are obtained at each c�rcolation test hole. All data to be submitted
for review.
2) Depth measurements to ire made from too of hole.
TEST PIT DATA REQUIRED TO BE SUBMITTED WITH APPLICRILILM
DESCRIPTION OF SOILS ENCXXJWERED IN TEST HOLES a-
DEPTH HOLE NO. % HOLE NO- 7v HOLE NO._ _ HOLE NO-
12
18" 5(5y 2 G G �Jye
30 ".
36"
42"
54"
60"
66"
72"
78"
84"
INDICATE LEVEL AT WHICH GROUND WATER IS ENCOUNTERED !�
x• - ItvuZiiF::�;FlEL k�OR- .b^?�i]C('fi. =WATER LEVEL RISES AFTER BEING ENCOUNTERED -TESTS
DESIGN
Soil Rate Used Min /1 "Drop: S.Do Usable Area Provided gip®
No. of Bedrooms Septic Tank Capacity/016i,,- Gals. Masonry �M tal
Absorption Area Prov. by�% L. F. x24" 36" width trench. Other
Name / Signature . oil OF
"'F`►v
Address �/�i�i'/1/ .� SM
sber County Health Depa
Soil Rate Approved Sq.Ft: /(;31. Checked by
Da to
S.1)- 27.6
r
14-16.4 (2187)—Text 12
PROJECT I.D. NUMBER 817.21 SEOR
Appendix C
tats Environmental duality'R&Iew'
SHORT. ENVIRONMENTAL ASSESSMENT FORM
For UNLISTED ACTIONS Only
PART I— PROJECT INFORMATION (To be completed by Applicant or Project sponsor)
1. APPLICANT /SPONSOR_ r
2. PROJECT NAME���
3. PR CT LOCATION:
Municipality �� C/ County
4. PRECISE LOCATION (Street address and road Intersect ns, prominent landmarks, etc., or provide map)
crC�lr ✓ Jj�ilCrf� `/� /C�/r/�
5. IS PROPOSED ACTION:
ew ❑ Expansion ❑ Modificationialteration
6. DESCRIBE PROJECT BRIEFLY: `
7. AMOUNT OF LAND AFFECTED:
Initially acres Ultimately acres
8. WILL PROPOSED ACTION COMPLY WITH EXISTING ZONING OR OTHER EXISTING LAND USE RESTRICTIONS?
Ayes ❑ No If No, describe briefly
9. WHAT _ IS PRESENT LAND USE IN VICINITY OF PROJECT?
+esidential Industrial, erclal ❑ ParklForest /O. _ Other _
_ ❑ Q CAmm _ ❑Agriculture nen,SQacn Q
l
10. DOES ACTION INVOLVE A PERMIT APPROVAL, OR FUNDING, NOW OR ULTIMATELY FROM ANY OTHER GOVERNMENTAL AGENCY (FEDERAL,
STATE OR LOCAL)? . • � /�`
19Yes 11 No If yes, list agenoy(s) and permlUspprovala / /)��y /va.
11. DOES ANY ASPECT OF THE ACTION HAVE A CURRENTLY VALID PERMIT OR APPROVAL?
lzYes ❑ No If yes, list agency name and permldapproval
12. AS A RESULT OF PROPOSED ACTION WILL EXISTING PERMITIAPPROVAL REQUIRE MODIFICATION?
❑
Yes No
I CERTIFY THAT THE INFORMATION PROVIDED ABOVE ISTRTRUE TO THE BEST OF MY KNOWLEDGE
Applicant/sponsor name: '� `� ' Date:
,
Signature: ZZ=l
If the action is in the Coastal Area, and yota are a state agency, complete the
Coastal Assessment Form before proceeding with this assessment
OVER
1
PAJIT II— ENVIRONMENTAL ASSESSMENT (To be comoleted-by Aaencv)
I
IV DOES ACTION EXCEED ANY TYPE 1 THRESHOLD IN 6 NYCRR, PART 617.12? If yes, coordinate the review process and use the FULL EAF.
❑ Yes ❑ No
B. WILL ACTION RECEIVE COORDINATED REVIEW AS PROVIDED FOR UNLISTED ACTIONS IN 6 NYCRR PART 617.6? If No, a negative declaration
may be superseded by another Involved agency..
C. COULD.ACTION RESULT IN ANY ADVERSE EFFECTS ASSOCIATED WITH THE FOLLOWING: (Answers may be handwritten, If legible)
C1. Existing air quality, surface or groundwater quality or quantity, noise levels, existing traffic patterns, solid waste production or disposal,
potential for erosion, drainage or flooding problems? Explain briefly:
C2. Aesthetic, agricultural, archaeological, historic, or other natural or cultural resources; or community or neighborhood character? Explain briefly:
C3. Vegetation or fauna, fish, shellfish or wildlife species, significant habitats, or threatened or endangered species? Explain briefly:
C4. A community's existing plans or goals as officially adopted, or a change in use or Intensity of use of land or other natural resources? Explain
C5. Growth, subsequent development, or related activities likely to be Induced by the proposed action? Explain briefly.
C6. Long term, short term, cumulative, or other effects not Identified In C1-057 Explain briefly.
C7. Other Impacts (including changes In use of either quantity or type_ of energy)? Explain briefly.
D. IS THERE; OR IS THERE LIKELY TO BE, CONTROVERSY RELATED TO POTENTIAL ADVERSE ENVIRONMENTAL IMPACTS?
_..
T1 .:. : " ❑.Ne ...Ys,
PART III — DETERMINATION OF SIGNIFICANCE (To be completed by Agency)
INSTRUCTIONS: For each adverse effect identified above, determine whether It Is substantial, large, Important or otherwise significant.
Each effect should be assessed In connection with Its (a) setting (i.e. urban or rural); (b) probability of occurring; (c) duration; (d)
Irreversibility; (e) geographic scope; and (f) magnitude. If necessary, add attachments or reference supporting materials. Ensure that
explanations contain sufficient detail to show that all relevant adverse Impacts have been identified and adequately addressed.
❑ Check this box If you have identified one or more potentially large or significant adverse impacts which MAY
occur. Then proceed directly to the FULL EAF and/or prepare a positive declaration.
❑ Check this box- if you have determined, based on the Information and analysis above and any supporting
documentation, that the proposed action WILL NOT result in any significant adverse environmental Impacts
AND provide on attachments as necessary, the reasons supporting this determination:
Name of Lead Agency
Print or Type Name of Responsible Officer in Lead Agency . .
Signature of Responsible Officer in Lead Agency
Date
2
Title of Responsible Officer
Signature of Preparer (If different from responsible officer)
:S :
PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
11.iL' t Y Yoh " lr'
RE: Property of Az7
Located at
Gd4/
T/V Tax Map # 72. If Block / Lot 3-25,
Subdivision of
Subdivision Lot #
Gentlemen:
Fildd Map # Date Filed
This, letter is to authorize 17— el % `� `✓�
a duly licensed Professional Engineer or Registered Architect _ to apple for the required
wastewater treatment and/or water supply permit(s) to serve the above -noted property in accordance
with the standards, rules or regulations as promulgated by the Public Health Director of the Putnam
County Health Department, and to sign all necessary papers on .my behalf in connection with this
matter and to supervise the construction of said wastewater treatment and /or water supply systems
in conformity with the provisions of Article 145 and/or 147 of the Education Law, the Public Health
Law, and the Putnam County Sanitary Code.
Very truly yours,
�' �.�����.���'✓`' -� Gam-: � �'�`�
Countersigned: Signed: L�
P.E., R.A., # z (Owner of Property)
V`
Mailing Addre ` r , ��C�f Mailing Address:
g
All
Fry y
State :. °. p /G'� q� State `'V' Zip
Telephone: Telephone: % -7i a 2 '3
Form LA -97
PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
y __ � w � , r - .a. .S may_ , .. y. _ i1' 11 _, 'S f —YV ;bI'. w /ar:. • - r - _ hi�. �. .,. .. . . _ � . p....
RE: Property of A-76�-e_,le
Located at _1! � Vro��
7— Z d
T/V Tax Map # 72. J f Block �_ Lot
Subdivision of
Subdivision Lot #
Gentlemen:
Filed Map # — Date Filed
This, letter is to authorize d
a duly licensed Professional Engineer or Registered Architect — .__..... to apple for the regttirc:d
wastewater treatment and/or water supply permit(s) to serve the above -noted property in accordance
with the standards, rules or regulations as promulgated by the Public Health Director of the Putnam
County Health Department, and to sign all necessary papers on.my behalf in connection -with this
matter and to supervise the construction of said wastewater treatment and /or water supply systems
in conformity with the provisions of Article 145 and/or 147 of the Education Law, the Public Health
Law, and the Putnam County Sanitary Code.
Countersigned:
P.E., R.A., #
Very truly yours,
_e
Signed:' P'47__ L�
(Owner of Property)
Mailing
Mailing Address: 9' _ i �f/% i a p ✓! "'%�
PROJECT DESCRIP'T'ION: Construct residence, well, SSDS and drive
COMMENTS: A site inspection was made of the above captioned property, and the
following materials were reviewed:
1. Short Environmental Assessment Form, prepared by Frank Sullivan,
dated 7121/94.
0
2. "Topographical Map and Survey of Property for Angelo and Marion
�� /�1/� '' -r- -(.� 14,y Ylnn+al�i Da—M 1 .. T C w 1 A
... ....._.__. ._ ..o - ..... .'.a ..... .._. VN4W.f. -i i�Y�►V.6 ►r''L V.aKa.. ✓VSU..il1�, L/.:�Ii i�"IY1f"a`t�
3. "Erosion Control and Grading Plan", prepared by Joseph F. Sullivan,
P.E. dated 9/5/94.
4. "Proposed Sewage Disposal System ", prepared by Joseph F. Sullivan,
P.E., dated 7/27/94.
Based on this review, it was determined that the proposed construction will not have a
significant environmental impact. Therefore, a permit waiver is granted with the
following conditions:
1. All erosion control measures shall be in place prior to the initiation of grading and
grubbing work.
2. Disturbed soils shall be mulched and revegetated as soon as practicable following final
grading. All erosion control measures shall be maintained until site is completely
vegetated.
PrAZZOIA PMW
PERMIT WAIVEk _
TOWN CODE 63
FRESHWATER WETLANDS AND WATERCOURSES
SATE OF 1$$UE:
September 12, 1994
EXPIRATION DATE:
September 12, 1995
APPUCANT
Angelo and Marion Cazzola
PROPERTY..LOCATION:
Sprout Brook Road
TAR MAP A
72.19 -33
Wg OF P()PERTY:a
1.03 Acres
INSPECTION DATE(S):
July 199 1994
1NS 'FCTION BY:
BETH EVANS
PROJECT DESCRIP'T'ION: Construct residence, well, SSDS and drive
COMMENTS: A site inspection was made of the above captioned property, and the
following materials were reviewed:
1. Short Environmental Assessment Form, prepared by Frank Sullivan,
dated 7121/94.
0
2. "Topographical Map and Survey of Property for Angelo and Marion
�� /�1/� '' -r- -(.� 14,y Ylnn+al�i Da—M 1 .. T C w 1 A
... ....._.__. ._ ..o - ..... .'.a ..... .._. VN4W.f. -i i�Y�►V.6 ►r''L V.aKa.. ✓VSU..il1�, L/.:�Ii i�"IY1f"a`t�
3. "Erosion Control and Grading Plan", prepared by Joseph F. Sullivan,
P.E. dated 9/5/94.
4. "Proposed Sewage Disposal System ", prepared by Joseph F. Sullivan,
P.E., dated 7/27/94.
Based on this review, it was determined that the proposed construction will not have a
significant environmental impact. Therefore, a permit waiver is granted with the
following conditions:
1. All erosion control measures shall be in place prior to the initiation of grading and
grubbing work.
2. Disturbed soils shall be mulched and revegetated as soon as practicable following final
grading. All erosion control measures shall be maintained until site is completely
vegetated.
PrAZZOIA PMW
Angelo and Marion Cazzola
Pane 2
3. It is not clear where the grading and clearing limit line is in the vicinity of the western
corner of the property. However, if earthwork is proposed immediately upgradient
and north of wetland flags #2 - 3, silt fencing should be installed at the edge of the
grading li- �.it line parallel to contour lines.
4. The Wetlands Inspector shall be notified prior to the initiation of grading and grubbing
work, once erosion control measures are in place.
Noncompliance with the conditions above will invalidate this waiver, and may result in a
Notice of Violation and/or a Stop Work Order. Any questions regarding this permit
waiver should be directed to the Town Wetlands Inspector or the office of the Building
Inspector.
Beth Evans
Town Wetlands Inspector
�c�►aou:hnv
G
TOWN CODE 63
FRESHWATER WETLANDS AND WATERCOURSES
APPLICANT /SPONSOR:
PROPERTY LOCATION:
TAR MAP #:
SIZE OF PROPERTY:
INSPECTION DATE(S):
INSPECTION BY:
PROJECT DESCRIPTION:
Angelo and Marion Cazzola
Sprout Brook Road
72.19-1-33
1.03 acres
July 19, 1994
BETH EVANS
Construct residence, well, SSDS and drive.
COIV %ff PT1�1 S: In addition to the site inspection of this property, the following
materials were reviewed for the application:
1. Short Environmental Assessment Form, prepared by Frank Sullivan, dated 7/21/94.
2. "Topographical Map and Survey of Property for Angelo and Marion Cazzola",
prepared by Donald Donnelly, L. S . , dated July 14, 1994-
.r. _. _.._ _ -.... _. a iai i vaiv w uTa� 'a'L'v..'w-ai� -v�iEu v� °ca�c: `► E � .c'� �va w� -'a!'�.:�a:.:t',:a- '::.��....0 �..,..:.• an - t C Sari=
inspection:
1. The wetland boundary at the western property line, as flagged by Evans Associates on
July 19, 1994 using flag #'s 1 - 3, should be survey located and shown on future
plans. The area flagged #1 - 3 is considered the beginning of a watercourse and is
associated with a regulated 50' setback.
2. A plan showing the following information should be submitted:
• location of the house, drive, SSDS and well
• watercourse boundary and associated 50' setback line
• proposed erosion control measures
• clearing and grading limit line
• proposed grading
y
Angelo andy Marion Cazzola_
e _ �si_ -v�:e i� � �i4L,i �IL �/ �e . -K « 4[,Y. - ��.•S- a ...x , �1.. � .. .. . �. .. - . e K • -w .,w r.._ . G}..w � ♦ .i - r.4 t . S K ... .
August 4, 1994
Page 2
3. The wetland /watercourse area flagged #1 - 3 should be located outside the clearing and
grading limit line and should be protected with sediment barriers.
4. Canopus Creek is located off- -site to the south and east. Erosion control barriers
should be placed downgradient of the southern edge of the clearing limit to protect this
watercourse.
If the disturbance limit line is not at least 100' from the high water mark of Canopus Creek,
which is a NYS DEC Class B watercourse, the NYS DEC Regulatory Affairs Office should
be contacted to determine if a NYS DEC permit is required. Any correspondence with the
NYS DEC should be copied to the Town of Putnam Valley.
Town Wetlands. Inspector
cc: Building Inspector
Environmental Commission
Planning Board
Joseph Sullivan, P.E✓
2972 Ferncrest Drive
Yak own i3eights, lv r iujy ?'
Field Time: 0.75 hours (includes delineation of watercourse)
Office Time: 0.5 hours
a I
110
FOR ASSESSMENT PURPOSES ONLY
NOT TO BE USED FOR CONVEYANCES
MUM 91
JAMES W. SEWALL COMPANY
I47 CENTER I.;TRFFT I'll n 'rnwm "A I Lw
AL
1.00 At
19 ii
SLATE LINE
COIXTY LIK
TM LIK
TILLAGE LIK
Lom LIMIT
J.t
i.
r;t
j;
OF HEALTH
ib a
\ DOvlelw ]A61? m PavvW.
'1„�
m CE811FiCATB oM
PnitC a
CONffi4lII CYBON Pane= I; SEWAGE VIVOSAL STStEM i
�fQ � t 'VM8"
q
Ica emd at r 'v / �' :i MM or
L
Stlblm.r tdlme t!~a �aA Yz W a 3 ia T. 'I 2. � y > � ,� 3
.n �1
C
(- /L /rt /i o,'� C..-GZ �4',% Beaaad_❑ ❑
Owns /ANoae i94�"�
p �J / Daft of Pn"m As@rovd
zz )� 7 i /.US�I i A✓y��P
.`!J / -1 y Town rJ G -
a
Date Subdiv/i')sion Annroved "g Fee Enclosed Amrntnt r� C� �J
• •� "�
� / / �.� % �%�(/'4 Lot Area /� O -- � �G. Ptil Secdon ody f�aL VO�B
a'F
'}
Number d &+�ae�n Deaip Plow G P D
PCCHD NodDendou Is Rued Wbm FM In eoseplemd
Serfewas Soaesedo Syokm b anss o$ �QW li/ r.� Sep& Took
{
To bs amlbacbd by eao
f
+t.
Wafer sup*. PdAv S� Film �' don
an Y wawa+:. Sapy�ly BMW by _= ,�►daae..
� } �,
.f
1 represent .that 1 am wholly and completely responsible for the design and location of the proposed system($). 1) that the separate sewage disposal system
above described will be constructed as shown on the approved amendment thereto and in accordR tM stsndsrds, rules a regulations o nom
'
County Department of Health, and that on completion thereof a °Certificate of Constructio o satistacto►y to the Commissioner of NMkhwtll
be submitted to the Deportment. and a written guarantee will M fumishe0'the owner, �M assigns by the budder, that said bulkier will
i
ploce in goad operating condition any part of aid sewage disposal systerrt during the pill ) Immediately following thodate of the tau,.
=
ronce
of the ap 81 of tM Certificate of Construction Compliance of thi orig at sy o; 2y that the drilled well dOtptbe0 above
11
wIN M WuleO as shessrn on the approved plan and that said well will be Installed in turn rd
n } `
r a and r s of the Putnam
'F
;a
County Deportment of Meath. --
Date / Signed
P.E. PA.
Adds n �r f License Nn �'
'
>f :
APPROVED FOR CONSTRUCTION. T s approval expires two vans from t(ie to issued Ili{ u of the building has been undertaken and Is
Mroaable for cause Of "nay be amend or modified when consid ecessri }y by the Commtst)oi�i1 th. Any change or atteratbn of construction
,
'roqukssa new q!�mn Approved for disposal of domestic sa age, a private- wetir""' only. ".
Rev. ip/!q �
is
10/88 oats�T 7 6V � ' Title
t;
.r
Public Health Director
Associate Public Health Director
Director of Patient Services
DEPARTMENT OF HEALTH
1 Geneva Road
Brewster, New York 10509
Environmental Health (914) 278 - 6130 Fax (914) 278 - 7921
Nursing Services (914) 278 - 6558 Fax (914) 278 - 6085
Early Intervention (914) 278 - 6014 Fax (914) 278 - 6648
January 20, 1999 WIC (914) 278 - 6678 Fax (914) 278 - 6085
Frank Sullivan, PE
2972 Ferrlcrest Drive
Yorktown Heights, New York 10598
Re: Cozzola SSTS, Sprout Brook Road
TM# 72.19 -1 -33, (T) PV
,:Dear Mr. Sullivan:
This office has received and reviewed the renewal application for the above mentioned project. I
would like to offer the following comments for your consideration.
Documents
/1. Please complete application CP -97 (copy attached)
`' 2. Please complete application PC -97 (copy attached)
. Please complete Design Data Sheet DD -97 (copy attached)
General
Please provide proof, verifying a representative of this office has witnessed deep test holes.
This o fi ha ..o record-...
__ Please provide in writing that there is no wetlands on subject property or within 200' of
proposed SSTS. Please also show (note) on plan.
Plan
V1. Profile to include proposed expansion trench representation.
r1f Invert elevations on profile are not legible. Please clarify.
Provide finished floor and basement floor elevations on plan.
Plans to show layout of proposed 100% expansion trenches.
t,,-5. Dimensions to property line of well required.
This office will continue it review upon consideration of the above mentioned comments. Please feel
free to contact me at ext. 15�/�if you have any questions.
�� Very truly yours,
Adam B. Stiebeling
Asst:.. Public Health Engineer
AS:cj .
PUTNAM COUNTY DEPARTMENT OF HEALTi�
ONSTRUCTION PERMIT FOR SEWAGE TREATMENT SYSTEM
Date Subdivision
Owner /Applicant Name
Mailing Address
Town or Village u
T%x Map P2./ Block /Lot
Revision
4 Date of Previous Approval
Amount of Fee Enclosed 34U
l G
Building Type .1 e Lot Area No. of Bedrooms
Design Flow GPD / e,
Fill Section Only Depth Volume
PCHD NOTIFICATION IS RE UIRED WHEN FILL IS COMPLETED
Separate Sewerage System to consist of o v gallon septic tank and 30r, ,C F
Other Requirements:
To be constructed by
am. .- . _
.. ....� -..� '1.`�iav�- 1:i'w��:'l1. "� _ �.. .. �_.� �..i -.. ..- -.-.• _ _ ._y..,.. .. _ _ ..� ......r ._..
or: Private Supply Drilled by Al ca Address ` P Al
I represent that I am wholly and completely responsible for the design and location of the proposed system(s) and that the
separate sewage treatments sstem- described above will be constructed as shown on the approved amendment thereto and in
accordance with the standards, rules and regulations of the Putnam County Department of Health, and that on completion
thereof a "Certificate of Construction Compliance" satisfactory to the Public Health Director will be submitted to the
Department, and a written guarantee will be furnished the owner, his successors, heirs or assigns by the builder, that said
builder will place in good operating condition any part of said sewage treatment system during the period of two (2) years
immediately following the date of the issuance of the approval of the Certificate of Construction Compliance of the original
system or any repairs thereto. I
Signed: P.E. R.A. Date
Address y a ��- License # ;Z9
v.
�
APPRO FOR CONSTRU al expires two years from the date issued unless construction of the
sewage treatment system has been ected by the PCHD and is revocable for cause or may be amended or
modified when considered necessary b eY- ealth Director. Any revision or alteration of the approved plan requires
a new permit. Approved for discharge of domestic sanitary sewage only.
By: Title: Date:
White copy - HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Design Professional
Form CP -97
rl`b`� Dhli �i �mfra�ateaW HaaHh SKVIoe�. l'�me1. N.Y. IOS12 O PWvfd� 1
CONS RUMON PE "WI R SEWAGZ DMOSAL SYSTM Pak R ;
5,0 / �t /l' r 11%df 4 Town or Vskee �
6dlvfaM� Nuns � _5<tbd. Got / � Ter: Mep � � • /� Bbck
Owner /AppilelstNalals f% i%4�'/� r/t %r /i y,7 �oZ �� %q Retoew 0 Serwen ❑ F
Data of Pnvioae Approval
yea Mdrwie `J� % `Sri �' 11 W V Tpwn /00 N
j)arP Subdivision Avoroved Fee Enclosed amnur,t �O
311dubs 1ype1.� US i ,/7GG lrea ot A /, d 3 M Secdon o* D.Pa Vehme
N�bar et HeBeawaa ;ieaipla 1%w G ' P D O CU MID Nodbeatlbou b Rega4al Wben M Is cotapktsd
Separate Sawaaa Sya/eee a eaaaiat 6 ;0 oft Septic Tank
To be ommkaetsd by _ Addmu ;
Wstatr SW*. PdAt Sop* Ines_ {_ Addrea i
art �•+es S•PPl► Drdisd.b'Ir
Ofbar >1agldaeeetla --7
.. 1 represent -that 1 am wholly ale► completely resFa,�sible for the aesign and location of the proposed systern(s)i 1) that the teparate sewage dbposal system
above described wilt be constructed as shown�On tht approved amendment there to and in actor the standards, lutes a regu .M O the Putnam
County Department of NasKIN and that on crn:PMtion thereof a!'Certifirate of Constructil o ' satisfactory to the Commis"nw of HwKhwill
be submitted to the Department, and a writtsn "&rant** will be fumishad the ow n&. hie lie assigns by the bulkier. that said bullde will
*We in good opwating condition any pert c, .sald wtva"e disposal system during the PW immediately following thedate of the tau-
anca of the approval of the Certificate of Carstruction Compliance of the original ty . a re of 2) that the drilled well described above
will be faceted as shown on the approved plan aad'that said well will be installed I iFotftn rd r s and u ns of the Putnam
CountyOapartmont of Health. r`
hate / /� Z/ • / ! Signed P.E.- RRJk
-y G y
Address- License Ho
APPROVED FOR CONSTRUCTION: T s approval expires two years from the to Issued ~uij utt! of the building has been undertaken and is !'
revotable for cause or may be amend or mcGified when consid ecessary by the Comrirlsrfo`�Y? „', the Any Change or alteration of construction ;
re4uhes a Mw nit Approved for dispoasl of domestic Y age, a mt�� atiP= sestRi y only a
Rev. o. :. i �� �9 �% By /E-'
10/88 T itle
..
14 -
i
i ,
PUTNAM COUNTY DEPARTMENT OF'HEALTH
DIVISION OF ENVIRONMENTAL HEALTH
INDIVIDUAL WATER SUPPLY & SUBSURFACE SEWACE.TREATSIF,.NT SYSTEMS - µ
CC�ZTRUtIMNiihviAI
STREET LOCATION 120ij,'I �'Ac O& _. NAME OF OWNER C 0 -z7,o �'ra
REVIEWED BY R GR, AS, MB, BH DATE TAX bi.AP # 7z
A
PWS LETTER
PORT EAF
LANS - THREE SETS
PeE PLANS - TWO SETS
ARIANCE REQUEST
l ✓I pht
SUBDIVISION
EGAL SUBDIVISION
vo SUBDIVISION, APPROVAL CHECKED
PERC RATE
FILL REQUIRED DEPTH
CURTAIN DRAIN REQUIRED
STANDPIPES
GENERAL
TED IN NYC WATERSHED
S SUBMITTED TO DEP
SATED TO D
YPR . IF REO'D
TER BI/ZBA
YR. FLOOD ELEVATION
IER REQ'D PERMIJ,(S)
GRAVITY FLOW
CONSTRUCTION NOTES
6ESIGN DATA: PERC & DEEP RESULTS
T CONTOURS EXISTING & PROPOSED
pRIVEWAY & SLOPES, CUT
FOOTING /GUTTER/CURTAIN DRAINS
SOIL TYPE BOUNDARIES
TITLE BLOCK; OWNERS NAME,ADDRESS
EROSION CONTROL:HOUSE,WELL, SSDS
PERC & DEEP HOLES LOCATED
REPRESENTATIVE OF PRIMARY & EXPANSION
LOCATION MAP
E AREA; SHOWN; GRAVITY FLOW, SUFF.SIZE
PUMPED, PIT & D BOX SHOWN & DETAILED
HOUSE - NO.OF BEDROOMS
WELLS & SSDS'S W/IN 200' OF PROPOSED SYS.
PROPERTY METES & BOUNDS
riOUSE SETBACK NECESSARY (TIGHT LOT)
HOUSE SEWER - 1/4" FT. 4 "0; TYPE PIPE
NO BENDS; MAX.BENDS 45° W /CLEANOUT
FILL SYSTEMS
CLAY BARRIER
10- FT. ORIZONTAL;S j OPE 3:1 TO GRADE
l�' L SPEC- _ FILL NOTES
3 D R'
420
(00p
FILE PROFILE & DIMENSIONS
VOLUME
FILL IN EXPANSION AREA
TRENCH
F TRENCH PROVIDED jai 60 FT MAX.
PARALLEL TO CONTOURS
100% EXPANSION PROVIDED
SEPARATION DISTANCES SPECIFIED
ON PLAN - FROM SSTS
"'TO
iIRIVF 1VA,v t;a rr_
20' TO FOUNDATION WALLS _15 -WELL TO PL
100' TO WELL, 200' IN DLOD, 150' PITS
100' TO STREAM WATERCOURSE LAKE (inc. expan)
50' TO CATCH BASIN, 35' STORMDRAIN, PIPED WATER
0' TO WATER LINE (pits -20')
50' INTERMITTENT DRAINAGE COURSE
2007500' RESERVOIR, ETC. —150' GALLEY SYSTEMS
15'MIN to CDS= >5 %,10'- 4 0/o,25'- 3 0/o,30'- 2 0/o,35' -1 0/*,100' - <I%
1,0'MIN to CD discharge /100'with 182 cons day discharge
SEPTIC TANK
10' FROM FOUNDATION; 50'-TO WELL
C i=
BRUCE R. FOLEY
:.;�,.•„ �;...._., P., :�i. ,'c�ii� r,ri`'d•R�.^>iFlrr= . ... ,.. w,...�.r... _ >. a. -..
LORETTA MOLINARI R.N., M.S.N.
..�,.::.... ... H- Ii "s:'�;;ia =� • Pa�di: 're�'::Y"�tir;;ttsr . . -:y- '::...;
Director of Patient Services
DEPARTMENT OF HEALTH
1 Geneva Road
Brewster, New York 10509
Environmental Health (914) 278 - 6130 Fax (914) 278 - 7921. .
Nursing Services (914) 278 - 6558 Fax (914) 278 - 6085
Early Intervention (914) 278 - 6014 Fax (914) 278 - 6648
January 20, 1999 WIC (914) 278 - 6678 Fax (914) 278 - 6085
Frank Sullivan, PE
2972 Ferncrest Drive
Yorktown Heights, New York 10598
Re: Cozzola SSTS, Sprout Brook Road
TM# 72.19 -1 -33, (T) PV
Dear Mr. Sullivan:
ne-11
This office has received and reviewed the renewal application for the above mentioned project. I
would like to offer the following comments for your consideration.
dcliments
iz Please complete application CP -97 (copy attached)
Please complete application PC -97 (copy attached)
Please complete Design Data Sheet DD -97 (copy attached)
neral
Please provide proof, verifying a representative of this office has witnessed deep test holes.
This office has no record.
i�'iiv vvEtla1'ldJ'UwSiai1JC'l:l p1VliC1'i:y'Ui W1tI1111'Gl1U'U1
proposed SSTS. Please also show (note) on plan.
P
Profile to include proposed expansion trench representation.
z Invert elevations on profile are not legible. Please clarify.
Provide finished floor and basement floor elevations on plan.
Plans to show layout of proposed 100% expansion trenches.
Dimensions to property line of well required.
This office will continue its review upon consideration of the above mentioned comments. Please feel
free to contact me at ext. 157 if you have any questions.
Very truly yours,
Adam B. Stiebeling
Asst.. Public Health Engineer
AS:cj
PUTNAM COUNTY DEPARTMENT OF HEALTH
ISION OF ENVIRO1NMENTAL HEALTH SERVICES
NSTRUCTION PERMIT FOR SEWAGE TREATMENT SYSTEM
Date Subdivision
Owner /Applicant Name
Mailing Address
Town or Village c— �p2
�Nx Map P2. /f Block /Lot 3-3.
4 Date of Previous Approval
Amount of Fee Enclosed SOU
� c
Building Type r- Lot Area No. of Bedrooms
p . /3Gs'
3 Design Flow GPD Z a 01
Fill Section Only Depth Volume
PCHD NOTIFICATION IS REQUIRED WHEN FILL IS COMPLETED
Separate Sewerage System to consist of gallon septic tank and 30ev J F
/
Other Requirements:
To be constructed by
Water Supply: u is . upp y rom
or: Private Supply Drilled by Address
._ X
I represent that I am wholly and completely responsible for the design and location of the proposed system(s) and that the
separate sewage treatment s,, system described above will be constructed as shown on the approved amendment thereto and in
accordance with the standards, rules and regulations of the Putnam County Department of Health, and that on completion
thereof a "Certificate of Construction Compliance" satisfactory to the Public Health Director will be submitted to the
Department, and a written guarantee will be furnished the owner, his successors, heirs or assigns by the builder, that said
builder will place in good operating condition any part of said sewage treatment system during the period of two (2) years
immediately following the date of the issuance of the approval of the Certificate of Construction Compliance of the original
system or any repairs thereto. I
Signed:
Address
P.E. /1--*" R.A. Date
dam- License # 6 ��
APPROVfib FOR CONS TRU I al expires two years from the date issued unless construction of the
sewage treatment system has been ected by the PCHD and is revocable for cause or may be amended or
modified when considered necessary b e• ealth Director. Any revision or alteration of the approved plan requires
a new permit. Approved for discharge of domestic sanitary sewage only.
�:
Title: Date:
White copy - HD File; Yellow copy - Building Inspector; Pink copy - Owner; Orange copy - Design Professional
Form CP -97
:.PUTNAM.COUNTY DEPARTMENT OF HEALTH
•.:'4.:. ?i'.:��- ,._�.d.:: '"" ='R., �r:, s r Lt. a ki - ^C•,'1C� C r .'-i: L.• !' L'^�f.J. -7�n?.
l� i�r �'. ..�:T k' mss.:.
1. Name and Address of Applicant:
Ile
d �
2. Name of Project: � � � /� 3. Location T /V /C:
4. Project Engineer: 5. Address:
L1_cense Number: Zy�i�s Phone:
b
6. I-ype of Project:
-Private/Residential Food Service Commercial
Apartments Institutional Mobile Home Park
Office Building Realty Subdivision Other (specify)
7. Is this project subject to State Environmental Quality Review (SEAR)? �v
Tvoe Status (Check One) Type I.. Exempt
Type II. Unlisted
8. Is.a Draft Environmental Impact Statement (DEIS) required? ............. oVv
9: Has DEIS been.completed and found .acceptable by Lead Agency? ...........
10. Name of Lead Agency .�
this .crnjsct.An an. area- .,-,nder:the- control-:ofJoca.l p.la;nning, zoning, =
or other officals, ordinances: ... ........ ... `•� -°�--�°�---�
12. If_.so, have plans been submitted to such authorities? .....I .............
13. Has preliminary approval. been granted by such authorities? Date Granted:
14. Type of Sewage Disposal System Discharge...... Surface Water
1l`*�Ground Waters
15. If surface water discharge, what is the stream class designation ?........
16. Waters index number (surface) .....................................
17. Is project .located near a public water supply system? .................. �G
18. If yes, name of water supply Distance to water supply Jam% %1
19. Is project site near a public sewage collection or disposal system?.....0
20. Name of sewage system Distance to sewage system
21 ate test holes observed: 22. Name of Health Inspector:
23. Project design flow (gallons per day) ....... .................:.............
11/93
WESTCHES'rER COUNTY DEPARTMENT OF HCAr,rH
-` �' - '� B ., '3.'i _ z .. a . V - 4 �i�1ur.JJl....4rS -1 ..v ter. 1'f> ..c v v _ sc, - _.. ..✓+ o. K... -
19 Bradhurst Avenue', +~
c . Hawthorns, New York 13532
DESIGN DATA S - SSE'PARATE SEWERAGE SYSTEM 'l F.'ILE /
Own-er .. p l� G,Z�O l/ Address
Located at (Street) � /e/c � Sec lock % Lot 3-3
radio to nearest cross St.
Municipality /1�5a' Watershed
i
SOIL PERCOLATION TEST DATA REQUIRED TO BE SUBMITTED WITH APPLICATION
HOLE #
CLACK TIME
PERCOLATION °
Hole
Number
Run
No.
Start Stop
Elapse
Time
Min.
Depth to Water
From Grd Surface
Start Stop
Inches Inches
Water bevel
In Inches
Drop
In Inches
Soil
Rate
min/in
Drop
1
P0
4
5
2
3
3-7
40
Z%
4
4r -
5
1
2
3
4
5.
V"U-1S:
1T —Tests to 'oe repeated at sama- depth until approximately equal soil, rates,
are obtained at each percolation test hole. All data to be suomitted
for review.
2) Depth measurements. to ire made f-coin top of hole.
REGISTERED ARCHITECT .
33' HILLCREST AVE.
OSSINING, NY 10562
[914] 762 -9029
r,
4, OF I A 4 A. -r A L K- A '* ?T.Njg:$ 'FOR BEDROOM COUNT ONLY,
4;z3 6rr-od.r .t FapK— Via➢ ;`.3
AI.i, .aLiT3 C i ,� . � J' it: ;tF1 iJ ?!(t�I�Ei3� fitQi�T TO THE JIOU',$g
PLANS WiS W WL'U£`:I` }`31i ':110, v1 -lB ,'PCDO,H?P,9p AP"fi yA
2
Sc `TITL=E
rj4 .AI.E �'�a ®"
Was 4a.. X11rJ
W 14 38 Foo4 SSE o o
-VJ 1/10
4
0
;
17
fi -- 7
r-
. STI;�L G71�v�'�
LI_1 r1 _ —
!'
4F !I I_Jiu�
x 3 x 14 4 ra4.1�'
up
rj4 .AI.E �'�a ®"
Was 4a.. X11rJ
W 14 38 Foo4 SSE o o
-VJ 1/10
4
0
TWO STO '1
Mont omep y
The Montgomery as pictured, shows
optional window grills, panel style
shutters, window mantles, high pitch
roof and front door with double side-
lights and colonial surround mouldings.
- Garage Optional- Please Refer to Garage
Section
The Montgomery's plan utilizes popular
design features throughout. You can
choose either three or four bedroom
12 -5
4LLF
Kim Nook `� Family Rm
10 -6 x 13-0 18 -6 ;r 13 -0
Sa uo rra�"
,top" arnan
O
Dining Den
o
14 -6 x 13 -0 �i 1f 3 x 13 -0.
":
First Floor
second level plans. The den and master
bedroom each feature a charming angle
bay area.
i
44 ;
10-4
�.
-0 :10-
^5
BR 3
BR 2
Co
E -
r
BR 3
-
BR 2
Co
.11 -0 x 13 -0
11 -8 x 13 -0
�% . ,.,,
9 -0 x 13 -0
1 1 x -0'
/ltd
CASs
BR 1
BR' 4
E
R 1
M 15 -6 x 13 -0 !
10 -8 x 13-
15 -E'' 13 -0
P
-
10 -8 "CIO i-G rl A ,¢ J( D
Montgomery
second floor "Plan N'
Montgomery second floor "Plan I:"
;:
_.
i..
h i
Jlrs
The Montgomery as pictured, shows
optional window grills, panel style
shutters, window mantles, high pitch
roof and front door with double side-
lights and colonial surround mouldings.
- Garage Optional-Please Refer to Garage
Section
The Montgomery's plan utilizes popular
design features throughout. You can
choose either three or four bedroom
second level plans. The den and master
bedroom each feature a charming angle
bay area.
/7ri s i � tylC,�° Fm
17 n Re
AlI
OE CIf 10.4
.4J , ,-1
12 -5
Kit
Nook = Family fpm
10 -6 x 13 -0 18 -6 x 13-0
�. BC
Dining o Den
14 -6 x 13 -0 ` 11 -3 x 13 -0
OFO � M1O "TIM ! 10 BOOR T " '• �.
e
BR ! BR BR3
Go►b9e °
11 -0 x 13 -0 L 11 -8 x 13 -0 ; 9 -0 x 13 -t
ewou -_
16x Zo ° �J,;"
ILI
BR 'a BR 4
15 -6 x .13 -0 10 -8 x 13
'0_8 -V ,c �, seco A �¢ g
Montgomery nd floor °Plan A'
t
27-6 x 44 2430 Sq. Ft.
5 -0
BR 2
1 1 x -0
4L,
L, .Jiwiu ii
RA
" 15 -6 13 -0
Montgomery second floor Plan B- t
z.
r.
:t
•t
i
,q
Jlrs
The Montgomery as pictured, shows
optional window grills, panel style
shutters, window mantles, high pitch
roof and front door with double side-
lights and colonial surround mouldings.
- Garage Optional-Please Refer to Garage
Section
The Montgomery's plan utilizes popular
design features throughout. You can
choose either three or four bedroom
second level plans. The den and master
bedroom each feature a charming angle
bay area.
/7ri s i � tylC,�° Fm
17 n Re
AlI
OE CIf 10.4
.4J , ,-1
12 -5
Kit
Nook = Family fpm
10 -6 x 13 -0 18 -6 x 13-0
�. BC
Dining o Den
14 -6 x 13 -0 ` 11 -3 x 13 -0
OFO � M1O "TIM ! 10 BOOR T " '• �.
e
BR ! BR BR3
Go►b9e °
11 -0 x 13 -0 L 11 -8 x 13 -0 ; 9 -0 x 13 -t
ewou -_
16x Zo ° �J,;"
ILI
BR 'a BR 4
15 -6 x .13 -0 10 -8 x 13
'0_8 -V ,c �, seco A �¢ g
Montgomery nd floor °Plan A'
t
27-6 x 44 2430 Sq. Ft.
5 -0
BR 2
1 1 x -0
4L,
L, .Jiwiu ii
RA
" 15 -6 13 -0
Montgomery second floor Plan B- t
I rw-sionvihat i ern ,"64y,ini ib-mipistoly. rii66niiislo ior-,04 the oPo "i
or yste - - -
County - Department.6f %'Heafte.4 and that orckbonoist i"-theieof, a "Cortif icate of "Constructidi
- , �sstisI factory. . to the - ComMi,ssionef o
f Healthwill
,
be"mitted 4 th b�6kinki ant will, o.fuinIsh" the owner. a migns.s y,thbulidmi.that aii ;buikW
will
HIaCe art 9001111.0por h4-'cipt%iiltion'4`n'y part of s§W a m ,dispoul,.syitem-'durionqg,:,the, Wr6sdiitelj lot inj4fis"teof the Nsu-
i4l-d",:ivmd above
ol'of tf4-,c4"lfkite i�al, sy
�4 of Construction CornPilinia of �, the iiihali *Ihe drilW
ad' sho6 on tM faPprowd.is n a-n- d the so in n I -
and -4— m —
- of the Putnam
71
Ji
at* bs
License No—
or
i �04
APPROVED FOR C6ktTl;fLI6*l6l4:T appr XP *I two years tkim thecdate - "u of the building-has been undertaken and is
h., Any charts or alteration of construction
revocable for cause t or IF orj modified .wfwn.cdn$Id ry, b the Co
requires a now it A ov" for.disji6imli of-ilorn"I a, 'a pilvate- .water
Rev.
two av Title
10/88.
Cm
DEPARTMENT OF HEALTH
Division of Environmental Health Services
4 Geneva Road, Brewster, New-York 10509
(914) 278 -6130
:.: av _ .: • 'APPY;ILA lUI�T__,IO. `C:U1�1�1`Ifl?C'1 '� .........
PCHD PERMIT J G/ l
WELL LOCATION
Stree Address TT Village Ci y Tax Grid Number
WELL OWNER
Name Ma ing Address
'01" lello 4: �4_ F 1' S`f Af iQ,
CtPrivate
Public
USE OF WELL
1 - primary
2 - secondary
ORESIDENTIAL ❑ PUBLIC SUPPLY O AIR /COND /HEA PUMP
® BUSINESS O FARM O TEST /OBSERVATION
® INDUSTRIAL M INSTITUTIONAL O STAND -BY
O ABANDONED
O OTHER (specify
AMOUNT OF USE
YIELD SOUGHT __V— gpm /46 PEOPLE SERVED_ /EST. OF DAILY USAGE a al
❑ REPLACE EXISTING SUPPLY O TEST/ OBSERVATION GiADDITIONAL SUPPLY
NEW SUPPLY NEW DWELLING ® DEEPEN EXISTING WELL
REASON FOR
DRILLING
DETAILED
REASON FOR
DRILLING
WELL TYPE
DRILLED
DRIVEN ®DUG
aGRAVEL
OOTHER
IS WELL SITE SUBJECT TO FLOODING? YES NO
IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION: �-
Lot No.
WATER WELL CONTRACTOR: Name , � � Address: %9. A y
IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES 6o" NO
NAME OF PUBLIC WATER SUPPLY: a-s TOWN /VIL /CITY
T QTd
GT. ,m T A,a_ h�F
LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDED
/
QrON SEPARATE SHEET / �
(dat (signature).
PERMIT TO CONSTRUCT A WATER WELL
This permit to construct one water well as set forth above is granted under the provisions
of Subpart 5 -2 of Part 5 of the New York State Sanitary Code, and provided that within
thirty (30) days of the completion of water well construction, the applicant shall:
1. Pump the well until the water is clear.
2. Disinfect the well in accordance with the requirements of the Putnam County Health
Department attached to this permit.
3. Submit a Well Completion Report on a form provided by the Putnam County Health Department.
During all well drilling operations, the applicant
any and all water or waste products from such well
property and in such manner as not to degr de or
Date of Issue: a 19
Date of Expiration 3 19
Permit is Non - Transferrable White
3/89 Yello,
shall take appropriate action to assure that
drilling operations be contained on this
r ise cont minate surface or groundwater.
ermit I ui g Offici
copy: HD File IVnk copy: Owner
a copy: Bldg. Insp. Orange copy: Well Driller
DEPARTMENT OF HEALTH
Division Of Environmental Health Services
4 Geneva Road, Brewster, New York 10509
(914) 278 -6130
August 17, 1994
Frank Sullivan
2972 Ferncrest Drive
Yorktown Heights, NY 10598
Re: Proposed SSDS: Cozzola
Canopus Hollow Road
(T) Putnam Valley
Dear Mr. Sullivan:
- .40HN KARFLL Jr... P.E,. M'S,
Public Health Director
Review of plans and other supporting documents submitted at this time relative to
the above- captioned project has been completed. Comments are offered as follows:
"The construction of this sewage disposal system may be subject to local wetlands
regulations. You should contact local wetlands officials in this regard."
1. Standard Form PC -1 has not been completed, specifically responses to
questions 13, 23, 28 and 32 have not been noted (PC -1 enclosed).
2. Deep test holes must be witnessed by a representative of this Department.
_ .... ...._ _.....,
:s �
been i
_.�::. Er;cc17 ee.rs ytl7or..i, t �. had
Upon Receipt of a submission, revised to reflect the above comments, this
application will be considered further.
Very truly yours,
Robert Morris, P. E.
Public Health Engineer
RM/j P
encl. (2)
PUTNAM COUNTY DEPARTMENT OF HEALTH
n ,., 3r- . �.. -., v:r�.._....r .�-..y ..... «.. u„ ai^.a: Va=s. Fri �V`lv >.,, U',�1�-' ^ ^'awl ` °J �11.Liv "Y'1L"1`Y�' 1`Yi3i�.J�. .7� i�•.:.1� .:Y� ,e= •,ra�...
Date �,L.��! /f�y
Re: Property of
Located at L jf�f ®p%` /G fit/ a
/�C% �C
(T) ovr Section 72.,J Block Lot
Subdivision of
Subdv. Lot # V Filed Map.# Date
Gentlemen:
This letter is to authorize ® 4!-o'
U.
a duly licensed professional engineer P or registered architect
(Indicate
to apply for a Construction Permit for a separate sewage system, to
serve the above noted property in accordance with the standards, rules
or regulations as promulagated by the Commissioner of the Putnam County
Department of Health, and to sign all necessary papers on my behalf in
,......__ __,:- ,P�:,3�:.�G., �i;;� ..�t:��th�•a �,�� -. -� �i � � ��.� - ��- n�r•w��� =a:. �fa.< .a -��,
system or systems in conformity with the provisions of Article 145 or
147, Education Law, the Public Health Law, and the Putnam County Sani-
tary Code.
Very truly ours,
4� ayr-&-
Signed 6 A e
Own of Property
41 T - s 9 TO � w Ay
�� ���
Address
(L,Sh,,VC • y , �13� ��
Town
T lee phone
1- -7f�- - 3 Sr 7 5•-
Telephone
j =APPENDIX 3
PUTNAM COUNTY DEPARTMENT OF HEALTH`- DIVISION OF ENVIRONMENTAL HEALTH SERVICES
INDIVIDUAL WATER SUPPLY & SUBSURFACE SEWAGE DISPOSAL SYSTEMS _
=s,.. ,,...:a- ,,... -•_r. '.T :- r,. -�.�, _.< j;a�.. o -I'�i: ��^T:I's3 i.✓lx- `4'E,L+ph L=L�4
NAME OF OWNEft /� //' `� STREET LOCATION
BY DATE ew �zwL /li TAX MAP #
,DOCUMENTS.
Y
PERMIT APPLICATION
m PC -1
E WELL PERMIT;m PWS LETTER
ENGINEERS AUTHORIZATIONA
DESIGN DATA SHEET(DDS)
DEEP HOLE LOG
CONSISTENT PERC RESULTS (3)_
PERC HOLE DEPTH
CORPORATE RESOLUTION
PLANS THREE SETS
L� HOUSE PLANS - TWO SETS
VARIANCE REQUEST
GENERAL
LEGAL SUBDIVISION
SUBDIVISION APPROVAL CHECKED
PERC RATE
M FILL REQUIRED
M CURTAIN DRAIN REQUIRED mSTANDPIPES
ED EX- APPROVAL SSDS ADJ. LOTS
m WETLAND (TOWN/DEC PERMIT R & D)
DATA ON DDS PLANS & PERMIT SAME
PRE- 1969 - NEIGHBOR NOTIFIFICATION
LETTER BI/ZBA
'SEWAGE SYSTEM PLAN - (NORTH ARROW)
SSDS HYDRAULIC PROFILE m GRAVITY FLOW
D/ J BOX M TRENCH/GALLEY m P- PIT DETAILS
SEPTIC TANK - SIZE, DETAIL
WELL DETAIL, SERVICE LINE IF OVER
CONSTRUCTION NOTES (GRINDER RATE)
DESIGN DATA: PERC AND DEEP RESULTS-
TWO-FOOT CONTOURS EXISTING & PROPOSED
DRIVEWAY & SLOPES CUT
FOOTING /GUTTER/CURTAIN DRAINS
COMMENTS:
1-3
3'z
DISCHARGE
[HOUSE ERC & DEEP HOLES LOCATED
EPRESENTATIVE OF PRIMARY AND EXPANSION
XP. ARE
SHOWN; GRAVITY FLOW, SUFF.SIZE
PUMPED PIT & D BOX SHOWN &DETAILED
OUSE - NO. OF BEDROOMS
ELLS & SSDS'S WAN 200 FT. OF PROPOSED SYSTEM
ROPERTY METES &BOUNDS
OUSE SETBACK NECESSARY (TIGHT LOT)
SEWER - 1 /4 "/FT. 4 "0; TYPE PIPE
O BENDS; MAX. BENDS 45 W /CLEANOUT
FILL SYSTEMS
CLAYBARRIER
10 FT HORIZONTAL: SLOPE 3:1 TO GRADE
FILL SPECS
DEPTH GAUGES
FILL PROFILE & DIMENSIONS
VOLUME
TRENCH
MLF TRENCH PROVIDED
1:060 FT MAX
® PARALLEL TO CONTOURS
100% EXPANSION PROVIDED
a_ 10' TO P.L., DRIVEWAY, LARGE TREES; TOP OF FILL
20' TO FOUNDATION WALLS
100 TO WELL, 200' IN D.L.O.D., 150' PITS
100 TO STREAM WATERCOURSE LAKE (INC.EXPAN)
50' TO CATCH BASIN, 35' STORMDRAIN, PIPED WATER
10' TO WATERLINE (PITS -20')
50' INTERMITTENT DRAINAGE COURSE
Q� 200 FT. RESERVOIR, ETC.E0 150 FT. GALLEY SYSTEMS
SEPTIC TANKS
m 10' FROM FOUNDATION; 50' TO WELL
WELLS
M15' WELLTOP.L.